Abstract
Revision total knee arthroplasty (TKA) in the setting of major bone deficiency and/or soft tissue laxity might require increasing levels of constraint to restore knee stability. However, increasing the level of constraint not always correlates with mid-to-long-term satisfactory results. Recently, modular components as tantalum cones and titanium sleeves have been introduced to the market with the goal of obtaining better fixation where bone deficiency is an issue; theoretically, satisfactory meta-diaphyseal fixation can reduce the mechanical stress at the level of the joint line, reducing the need for high levels of constraint. This article reviews the recent literature on the surgical management of the unstable TKA with the goal to propose a modern surgical algorithm for adult reconstruction surgeons.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance
Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM. Insall award paper: why are total knee arthroplasty failing today? Clin Orthop Relat Res. 2002;404:7–13. This study reviews current mechanisms of failure of total knee arthroplasties. The reasons for failure listed in order of prevalence among the patients in this study include polyethylene wear, aseptic loosening, instability, infection, arthrofibrosis, malalignment or malposition, deficient extensor mechanism, avascular necrosis in the patella, periprosthetic fracture, and isolated patellar resurfacing.
Rodriguez-Merchan EC. Instability following total knee arthroplasty. HSS J. 2011;7:273–8.
Vince KG, Abdeen A, Sugimori T. The unstable total knee arthroplasty: causes and cures. J Arthroplasty. 2006;21(4 Suppl 1):44–9.
Gonzalez MH, Mekhail AO. The failed total knee arthroplasty: evaluation and etiology. J Am Acad Orthop Surg. 2004;12:436–46.
Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ. Flexion instability after primary posterior cruciate retaining total knee arthroplasty. Clin Orthop Relat Res. 1998;356:39–46.
Math KR, Zaidi SF, Petchprapa C, Harwin SF. Imaging of total knee arthroplasty. Semin Musculoskelet Radiol. 2006;10:47–63.
Volpe L, Indelli PF, Latella L, Poli P, Yakupoglu KJ, Marcucci M. Periprosthetic joint infections (PJI): a clinical practice algorithm. Joints. 2014;2(4):169–74.
Aggarwal VK, Tischler E, Ghanem E, Parvizi J. Leukocyte esterase from synovial fluid aspirate: a technical note. J Arthroplasty. 2013;28:193–5.
Song SJ, Detch RC, Maloney WJ, Goodman SB, Huddleston 3rd JI. Causes of instability after total knee arthroplasty. J Arthroplasty. 2014;29(2):360–4. The purpose of the present study was to characterize the underlying causes that lead to instability after total knee arthroplasty (TKA). The authors reviewed 83 revision TKAs (79 patients) performed for instability, identifying six categories of causes: flexion/extension gap mismatch, component malposition, isolated ligament insufficiency, extensor mechanism insufficiency, component loosening, and global instability.
Azzam K, Parvizi J, Kaufman D, Purtill JJ, Sharkey PF, Austin MS. Revision of the unstable total knee arthroplasty: outcome predictors. J Arthroplasty. 2011;26(8):1139–44. doi:10.1016/j.arth.2011.02.028.
Phisitkul P, James SL, Wolf BR, Amendola A. MCL injuries of the knee: current concepts review. Iowa Orthop J. 2006;26:77–90.
Muller JK, Wentorf FA, Moore RE. Femoral and tibial insert downsizing increases the laxity envelope in TKA. Knee Surg Sports Traumatol Arthrosc. 2014;22(12):3003–11. doi:10.1007/s00167-014-3339-0.
Ryd L, Albrektsson BE, Carlsson L, et al. Roentgen stereophotogrammetric analysis as a predictor of mechanical loosening of knee prostheses. J Bone Joint Surg (Br). 1995;77(3):377.
Bugbee WD, Ammeen DJ, Engh GA. Does implant selection affect outcome of revision knee arthroplasty? J Arthroplasty. 2001;16:581–5.
Scuderi GR. Revision total knee arthroplasty: how much constraint is enough? Clin Orthop Relat Res. 2001;392:300–5.
Babis GC, Trousdale RT, Pagnano MW, Morrey BF. Poor outcomes of isolated tibial insert exchange and arthrolysis for the management of stiffness following total knee arthroplasty. J Bone Joint Surg Am. 2001;83(10):1534–6.
Babis GC, Trousdale RT, Morrey BF. The effectiveness of isolated tibial insert exchange in revision total knee arthroplasty. J Bone Joint Surg Am. 2002;84-A(1):64.
Waslewski GL, Marson BM, Benjamin JB. Early, incapacitating instability of posterior cruciate ligament-retaining total knee arthroplasty. J Arthroplasty. 1998;13(7):763–7.
Montgomery RL, Goodman SB, Csongradi J. Late rupture of the posterior cruciate ligament after total knee replacement. Iowa Orthop J. 1993;13:167.
Haidukewych GJ, Hanssen A, Jones RD. Methaphyseal fixation in revision total knee arthroplasty: indications and techniques. J Am Acad Orthop Surg. 2011;19(6):311–8.
Berend ME, Bertrand T. The role of implant constraint: not too little, not too much. Orthopedics. 2007;30(9):793.
Pritsch M, Fitzgerald Jr RH, Bryan RS. Surgical treatment of ligamentous instability after total knee arthroplasty. Arch Orthop Trauma Surg. 1984;102:154–8.
Lombardi AV, Berend KR. Posterior cruciate ligament retaining, posterior stabilized, and varus/valgus posterior stabilized constrained articulations in total knee arthroplasty. Instr Course Lect. 2006;55:419–27.
Easley ME, Insall JN, Scuderi GR, Bullek DD. Primary constrained condylar knee arthroplasty for the arthritic valgus knee. Clin Orthop Relat Res. 2000;380:58–64.
Ward WG, Haight D, Ritchie P, Gordon S. Eckardt: dislocation of rotating hinge total knee prostheses. J Bone Joint Surg. 2003;85(A):448–63.
Haas SB, Insall JN, Montgomery 3rd W, et al. Revision total knee arthroplasty with use of modular components with stems inserted without cement. J Bone Joint Surg Am. 1995;77:1700.
Hwang SC, Kong JY, Nam DC, et al. Revision total knee arthroplasty with a cemented posterior stabilized, condylar constrained or fully constrained prosthesis: a minimum 2-year follow-up analysis. Clin Orthop Surg. 2010;2:112.
Shen C, Lichstein PM, Austin MS, Sharkey PF, Parvizi J. Revision knee arthroplasty for bone loss: choosing the right degree of constraint. J Arthroplasty. 2014;29:127–31. Revision total knee arthroplasty (TKA) in the setting of bone deficiency requires varied levels of constraint to restore knee stability. The authors showed that revision TKA conducted with increased constraint appears effective in the setting of increased bone deficiency.
Lachiewicz PF, Soileau ES. Fifteen-year survival and osteolysis associated with a modular posterior stabilized knee replacement. A concise follow-up of a previous report. J Bone Joint Surg Am. 2009;91:1419.
Engh GA, Parks NL. The management of bone defects in revision total knee arthroplasty. Instr Course Lect. 1997;46:227.
Barrack RL. Evolution of the rotating hinge for complex total knee arthroplasty. Clin Orthop Relat Res. 2001;392:292.
Hossain F, Patel S, Haddad FS. Midterm assessment of causes and results of revision total knee arthroplasty. Clin Orthop Relat Res. 2010;468:1221.
Kim YH, Kim JS. Revision total knee arthroplasty with use of a constrained condylar knee prosthesis. J Bone Joint Surg Am. 2009;91:1440.
Compliance with Ethics Guidelines
Conflict of Interest
The authors have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Author information
Authors and Affiliations
Corresponding author
Additional information
This article is part of the Topical Collection on Revision Knee Arthroplasty
Rights and permissions
About this article
Cite this article
Indelli, P.F., Giori, N. & Maloney, W. Level of constraint in revision knee arthroplasty. Curr Rev Musculoskelet Med 8, 390–397 (2015). https://doi.org/10.1007/s12178-015-9295-6
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12178-015-9295-6